From the Guidelines
Hemoptysis is classified into three degrees based on the volume of blood expectorated, with mild hemoptysis involving less than 100 mL of blood within 24 hours, moderate hemoptysis ranging from 100 to 600 mL in 24 hours, and severe or massive hemoptysis exceeding 600 mL in 24 hours or occurring at a rate greater than 150 mL per hour, as defined by the most recent guidelines 1.
Classification of Hemoptysis
The classification of hemoptysis is crucial in guiding clinical management decisions. The degrees of hemoptysis are:
- Mild hemoptysis: less than 100 mL of blood within 24 hours
- Moderate hemoptysis: 100 to 600 mL in 24 hours
- Severe or massive hemoptysis: exceeds 600 mL in 24 hours or occurs at a rate greater than 150 mL per hour
Clinical Management
The management of hemoptysis varies depending on the degree of bleeding.
- Mild hemoptysis may be managed conservatively with close monitoring
- Moderate cases often require hospitalization for observation and diagnostic workup
- Severe hemoptysis constitutes a medical emergency requiring immediate intervention to secure the airway, stabilize the patient, and identify the bleeding source
Importance of Classification
The degree of hemoptysis matters because it correlates with mortality risk, with massive hemoptysis carrying a high mortality rate primarily due to asphyxiation rather than blood loss, as reported in a study published in the Journal of the American College of Radiology 1.
Key Considerations
Key considerations in the management of hemoptysis include:
- Securing and maintaining an adequate airway and optimal oxygenation
- Correcting any coagulopathy
- Considering tranexamic acid to promote clotting
- Performing bronchoscopy for localization and potential intervention, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1
From the Research
Degrees of Hemoptysis
The degrees of hemoptysis can be classified based on the quantity of expectorated blood. The following are the different degrees of hemoptysis:
- Minor: less than 30 mL of hemoptysis 2
- Moderate to severe (major): 30 to 300 mL of hemoptysis 2
- Massive: more than 300 to 400 mL in 24 hours 2 Hemoptysis can also be categorized as mild or massive, with mild hemoptysis comprising more than 90% of cases and having a good prognosis, whereas massive hemoptysis has a high mortality rate 3
Classification and Evaluation
The evaluation of hemoptysis includes determining the severity of bleeding and stability of the patient, and may require bronchoscopy for airway protection 3. The initial evaluation also includes a chest radiograph, although it has limited sensitivity for determining the site and etiology of the bleeding 3, 4. Computed tomography and computed tomography angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding 3, 4.
Management and Treatment
The management of hemoptysis begins with an initial assessment of gas exchange and hemodynamic stability, followed by an identification of the cause by means of fiberoptic bronchoscopy, and chest imaging studies to attain cessation of bleeding and to prevent future recurrence 5. Bronchial arterial embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography 3, 2, 4. Surgery is reserved for patients whose medical treatment and embolization are not effective 3, 4